Hodgkin's Disease in Bone

Abstract

Hodgkin's disease is not exclusively a disease of the lymphatic system. Involvement of every organ system including the skeleton has been reported. The present discussion of Hodgkin's disease in bone is based on a review of the literature and a study of 94 previously unreported cases from the Veterans Administration Research Hospital, Chicago, and the Evanston Hospital (Evanston, Ill.) of which 11 showed osseous involvement. Askanazy (2) described the pathologic aspects of osseous involvement in 1920, some twenty years after the clear definition of Hodgkin's disease as an entity by Reed and Sternberg. Grossman and Weis (6) first recorded the radiographic features of the bony lesions in 1922. Incidence The reported incidence of Hodgkin's disease in bone varies widely with the diagnostic criteria. A distinction must be made between medullary and cortical lesions. In the spongiosa the disease may be widespread without giving rise to symptoms or radiographic signs. The true incidence cannot be determined because of the limitations of the average postmortem examination. The more diligent the search of the bone marrow, the greater the apparent incidence (13). Ewing (5) believed that it approached 100 per cent in patients dying of the disease. Only when there is extensive destruction or sclerosis are the lesions discoverable radio-graphically. Cortical involvement is more readily detectable; radiographic evidence may be found antemortem in approximately 15 per cent of all cases of Hodgkin's disease (Table I), and Uehlinger (14) states that in an additional 10 per cent cortical lesions will be discovered only at autopsy. The mean age of occurrence of Hodgkin's disease is the fourth decade, and the peak incidence is in the third decade (8, 14, 15). These data correspond closely to cases with bone involvement. Although Uehlinger states that osseous lesions are a late and prognostically grave sign, the work of Vieta, Friedell, and Craver (15) and the new cases reviewed here do not substantiate this conclusion. Bone involvement occurs throughout the course of the disease, and its appearance does not affect the prognosis significantly. In this respect Hodgkin's disease differs from most metastatic tumors. The sex ratio is approximately equal. Signs and Symptoms Hodgkin's disease in cortical bone usually gives some indication of its presence, although large lesions are often found which have produced no signs or symptoms. The most common manifestation is localized pain. This may be intermittent or persistent and may occur in any phase of the disease. Negative radiographs may obscure its origin. Jackson and Parker (8) found that in 13 per cent of their cases symptoms were present for two to twelve months before positive radiographic findings were obtained. Occasionally pain without significant adenopathy directs attention to the disease.